The Impact of the COVID-19 Pandemic on Food Access: Insights from First-Person Accounts in a Safety-Net Health Care System.

The COVID-19 pandemic disproportionately affected populations that were already facing socioeconomic disadvantages and limited access to health care services. The livelihood of millions was further compromised when strict shelter-in-place measures forced them out of their jobs. The way that individuals accessed food during the early stages of the COVID-19 pandemic drastically changed as a result of declines in household income, food chain supply disruptions, and social distance measures. This qualitative study examined the food access experiences of participants enrolled in a safety-net health care system-based, free, monthly fruit and vegetable market in the Metro Boston area during the first six months of the COVID-19 pandemic. The findings offer rich qualitative information to understand the financial repercussions of the pandemic on food access.

Examining Racial/Ethnic Disparities in Tobacco Dependence Treatment Among Medicaid Beneficiaries Using Fifty State Medicaid Claims, 2009-2014.

In the USA, low-income racial/ethnic minority groups experience higher smoking rates and greater smoking-related disease burden than their White counterparts. Despite the adverse effects, racial/ethnic minorities are less likely to access tobacco dependence treatment (TDT). Medicaid is one of the largest payers of TDT in the USA and covers predominantly low-income populations. The extent of TDT use among beneficiaries from distinct racial/ethnic groups is unknown. The objective is to estimate racial/ethnic differences in TDT use among Medicaid fee-for-service beneficiaries. Using a retrospective study design and 50 state (including the District of Columbia) Medicaid claims (2009-2014), we employed multivariable logistic regression models and predictive margin methods to estimate TDT use rates among adults (18-64) enrolled (≥ 11 months) in Medicaid fee-for-service programs (January 2009-December 2014) by race/ethnicity. The population included White (n = 6,536,004), Black (n = 3,352,983), Latinx (n = 2,264,647), Asian (n = 451,448), and Native American/Alaskan Native (n = 206,472) beneficiaries. Dichotomous outcomes reflected service use in the past year. Any TDT use was operationalized as any smoking cessation medication fill, any smoking cessation counseling visit, or any smoking cessation outpatient visit. In secondary analyses, we disaggregated TDT use into three separate outcomes. Results suggested that Black (10.6%; 95% CI = 9.9-11.4%), Latinx (9.5%; 95% CI = 8.9-10.2%), Asian (3.7%; 95% CI = 3.4-4.1%), and Native American/Alaskan Native (13.7%; 95% CI = 12.7-14.7%) beneficiaries had lower TDT use rates compared to White beneficiaries (20.6%). Similar racial/ethnic treatment disparities were identified across all outcomes. By identifying significant racial/ethnic disparities in TDT use between 2009 and 2014, this study provides a benchmark against which to measure recent interventions in state Medicaid programs improving equity in smoking cessation interventions.

Criminal Legal Involvement Among U.S. Adults With Serious Psychological Distress and Differences by Race-Ethnicity.

OBJECTIVE: The authors examined associations between criminal legal involvement (CLI) and serious psychological distress and how these associations differed by racial-ethnic group. METHODS: The authors conducted a retrospective analysis of multiple cross-sections of data from the National Survey on Drug Use and Health (2015-2019) and used multivariable linear probability regression models to assess lifetime CLI and past-year probation, parole, supervised release, or other conditional release in a nationally representative sample of noninstitutionalized U.S. adults, ages ≥18 years (N=214,505), with and without serious psychological distress. RESULTS: Adults with serious psychological distress had higher rates of CLI than adults without such distress (difference of 4.1 percentage points, 95% CI=3.3-4.8, p<0.001). The rate of CLI increased as distress severity increased, from mild (3.2 percentage-point difference, 95% CI=2.6-3.8, p<0.001) to high (7.2 percentage-point difference, 95% CI=6.4-8.0, p<0.001). The risk for CLI among those with serious psychological distress was even greater for Black and Latinx adults than for White adults (1.8 percentage-point difference, 95% CI=0.1-3.5, p<0.05, and 3.2 percentage-point difference, 95% CI=1.3-5.2, p<0.01, respectively). CONCLUSIONS: Rates of CLI were higher for adults with serious psychological distress. Efforts are needed to equitably triage individuals with acute mental health needs to timely psychiatric care instead of carceral settings. Collaborative models of care that commingle resources from mental health and law enforcement organizations are needed to prevent unnecessary incarceration of individuals experiencing mental health crises and to increase access to community-based treatment.

Effects of Medicaid coverage on receipt of tobacco dependence treatment among Medicaid beneficiaries with substance use disorder.

OBJECTIVE: Individuals with substance use disorder (SUD) smoke cigarettes at a rate that is more than double the rate of the general population. Tobacco dependence treatment (TDT) is effective at reducing smoking, yet it is unclear whether expanding insurance coverage of these services increases TDT use among Medicaid beneficiaries with SUD. DATA SOURCE: 2009-2013 Medicaid data in all 50 states and Washington DC. STUDY DESIGN: We conducted a retrospective analysis of the 2009-2013 de-identified Medicaid Analytic Extract (MAX) claims for a 100% national sample of fee-for-service (FFS) Medicaid adult beneficiaries. Using a difference-in-difference-in-differences analysis, we assessed the association of full TDT coverage on TDT medication use and tobacco cessation counseling services between beneficiaries with and without SUD. We adjusted for age, sex, race/ethnicity, diagnosis of co-occurring chronic illness, state tobacco taxes, and state and year fixed effects. DATA COLLECTION/EXTRACTION METHODS: We excluded patients not continuously enrolled in Medicaid for 12 months during the calendar year, adults aged 65 and older (given their dual enrollment in Medicaid and Medicare), minors aged 12-17, and pregnant women (for whom different TDT coverage policies apply). PRINCIPAL FINDINGS: We separately modeled the association between full coverage of (1) counseling, (2) over-the-counter nicotine replacement therapy, and (3) prescription cessation medications on TDT medication treatment and counseling services. We found that each coverage led to increases in any TDT medication treatment and counseling services for beneficiaries with SUD. The effects of each coverage on medication treatment were greater for beneficiaries with SUD compared to beneficiaries without SUD (ranging from 4.9 to 6.1 percentage point difference). CONCLUSION: Coverage of tobacco cessation counseling, over-the-counter nicotine replacement therapy, and prescription cessation medications holds promise for reducing the wide disparities in rates of smoking between those with and without SUD.

Family Stressors and Resources as Social Determinants of Health among Caregivers and Young Children.

Life course-informed theories of development suggest it is important to integrate information about positive and negative aspects of the social environment into studies of child and parental wellbeing, including both stressors that compromise health and resources that promote well-being. We recruited a sample of 169 pairs of caregivers and young children (birth to 5 years) from a community health clinic and administered survey questions to assess stressors and resources. We constructed inventories of stressors and resources and examined the relationships between these inventories and caregivers' depressive symptoms, anxiety symptoms, and sleep problems, and young children's medical diagnoses derived from electronic health records. Cumulative stressors and resources displayed bivariate and adjusted associations with caregivers' depressive symptoms, anxiety symptoms, and sleep problems. For depressive and anxiety symptoms, these associations were evident in models that included stressors and resources together. Caregivers with high stressors and low resources displayed the highest levels of depressive and anxiety symptoms and sleep problems. In terms of children's health outcomes, only modest trends were evident for developmental/mental health outcomes, but not other diagnostic categories. Future studies are needed to examine stressors and resources together in larger samples and in relation to prospectively assessed measures of child well-being.

Understanding the Role of Past Health Care Discrimination in Help-Seeking and Shared Decision-Making for Depression Treatment Preferences.

As a part of a larger, mixed-methods research study, we conducted semi-structured interviews with 21 adults with depressive symptoms to understand the role that past health care discrimination plays in shaping help-seeking for depression treatment and receiving preferred treatment modalities. We recruited to achieve heterogeneity of racial/ethnic backgrounds and history of health care discrimination in our participant sample. Participants were Hispanic/Latino (n = 4), non-Hispanic/Latino Black (n = 8), or non-Hispanic/Latino White (n = 9). Twelve reported health care discrimination due to race/ethnicity, language, perceived social class, and/or mental health diagnosis. Health care discrimination exacerbated barriers to initiating and continuing depression treatment among patients from diverse backgrounds or with stigmatized mental health conditions. Treatment preferences emerged as fluid and shaped by shared decisions made within a trustworthy patient-provider relationship. However, patients who had experienced health care discrimination faced greater challenges to forming trusting relationships with providers and thus engaging in shared decision-making processes.